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A D V E R T O R I A L Circle 135 on the Reader Service Card The views expressed in this advertorial are those of the author only. Providers and clinicians are obligated to make their own determination of the appropriate medical treatment for each of their patients. Brought to you as an educational service by Long Acting Bupivacaine: Where Does it Fit In? Stuart A. Grant, MBBS, Durham, N.C. What about the idea of using liposomal bupivacaine for single-shot nerve blocks? Would these lipid capsules remain in the nerve plexus space and provide long-term pain control? The jury is still out, but the early signs are less than reassuring. In a company-sponsored study of 180 patients, the drug failed to show a consistent benefit. 6 Another small study of 14 volunteers showed that a single-shot femoral nerve block using the drug had an effect for greater than 24 hours, but the magnitude of the blocks varied widely. Strangely, the higher the dosage, the lesser the effect. 7 A worry is that single-shot injections of liposomal bupivacaine afford no opportunity to titrate. That could be a problem. For example, consider interscalene brachial plexus blocks. They can paralyze the diaphragm and send susceptible patients into respiratory failure. With liposomal bupivacaine, there would be no opportunity to turn the block off. Effective, long-lasting pain relief that's also convenient to administer remains a worthy goal. From what we know so far, though, liposomal bupivacaine falls short. Fortunately, we have a proven, highly effective alternative. CPNBs provide outstanding post-op pain control safely and effectively, for as long as our patients need it. Dr. Grant is a professor of anesthesiology at Duke University Medical School. PERHAPS THERE WILL COME A DAY when we can provide dependable, long- lasting post-op pain control that's also extremely convenient to administer. No need for ultrasound, nerve stimulators, catheters and pain pumps or the training necessary to administer them. Just infiltrate the wound or joint space. Maybe some day. Unfortunately, though, not today. When liposomal bupivacaine came to market, we were eager to try it, hopeful that this new drug could streamline post- op pain control. We administered long- acting bupivacaine on 150 total knee patients, evaluating their pain scores and time to discharge. The results were not what we had hoped. Some patients experienced significant relief early on, but others did not. The effects wore off for many patients early in the post-op period, necessitating opioids. We switched back to continuous nerve blocks. Researchers at other institutions encountered similar results: • A study comparing long-acting bupivacaine to old- fashioned infiltration of bupivacaine HCI in breast augmentation patients showed a difference in pain scores at eight and 12 hours, but no significant difference in pain scores through 72 hours. 1 • A study comparing wound infiltration of long-acting bupivacaine to traditional bupivacaine in total knee patients 2 found no difference between the two approaches. • A study comparing long-acting bupivacaine to placebo in hemorrhoidectomy patients showed a clear difference in pain scores for the first 12 hours. But by 24 hours long-acting bupivacaine did not perform better than placebo. 3 • A study comparing long-acting bupivacaine to placebo for bunionectomy showed a minimal advantage to bupivacaine at 12 hours and no advantage at 24 hours. 4 In contrast, studies of continuous nerve blocks show that they clearly perform better, providing effective, long- lasting analgesia. 5 1. Smoot JD, et al. The efficacy and safety of DepoFoam bupivacaine in patients undergoing bilateral, cosmetic, submuscular augmentation mammoplasty: a randomized, double-blind, active-control study. Aesthet Surg J. 2012;32(1):69–76. 2. Bramlett K, et al. A randomized, double-blind, dose-ranging study comparing wound infiltration of DepoFoam bupivacaine, an extended-release liposomal bupivacaine, to bupivacaine HCl for postsurgical analgesia in total knee arthroplasty. Knee. 2012 Jan 27 3. Gorfine SR, et al. Bupivacaine extended-release liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial. Dis Colon Rectum. 2011;54(12):1552–1559. 4. Golf M, et al. A phase 3, randomized, placebo-controlled trial of DepoFoam ® bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy. Adv Ther. 2011;28(9):776–788. 5. Ilfeld BM, Enneking, FK. Continuous Peripheral Nerve Blocks at Home: A Review. Anesth Analg 2005;100:1822–33 6. Pacira says pain drug Exparel fails in new study. Associated Press, Aug 1, 2013. 7. Ilfeld BM,et al. Liposomal bupivacaine as a single-injection peripheral nerve block: a dose- response study. Anesth Analg. 2013 Nov;117(5):1248-56. This pain-control product is convenient to administer, but it falls short of the gold standard in the measures that matter.